Intermountain-led CMS Hospital Engagement Network

Falls PreventionJuly 11, 2014 Affinity Call

Marlyn Conti –Patient Safety Initiatives Manager Intermountain Quality and Patient Safety

Outline for Discussion

• Review of data through Q1 2014• ‘High performers’ – Identify and ask what

they are doing?• Falls recommended metrics• “Just-one-thing” – updated document• 2014 plans for improvement:– Reach out to low performers to provide assistance– Continue Webinars for sharing

Overall Progress Through 2013

This is a 24.2% reduction from baseline which was below national benchmark

Intermountain HEN 2012- Q1 2014 submitting Inpatient Falls with Injury

Started at 0.65 Down to 0.47 in Q4, Red line is baseline

Intermountain HEN 2012- Q1 2014 submitting Inpatient Falls with Injury

Intermountain HEN 2012-Q1 2014 submitting Hospitals Inpatient Falls

Total number of falls is increasing while Falls with injury is reducing. Might be better reporting?

Intermountain HEN 2012-13 submitting Hospitals

Inpatient Falls

Number of reporting hospitals has dropped slightly. May increase the rate

HEN Falls Measures

• Metric specification resource manual http://www.henlearner.org/wp-content/uploads/2012/03/HEN_measure_Feb5.pdf

• Submission schedule: – May 20, 2014: for data through March 2014

HEN Falls MeasuresInpatient Falls

HEN Falls MeasuresFalls with Injury

High Performing Hospital Highlight… Most Improvement

Inpatient FallsMost Improvement

OREM COMMUNITY HOSPITAL

SANPETE VALLEY HOSPITAL - CAH

SOCORRO GENERAL HOSPITAL

PROVIDENCE SEASIDE HOSPITAL

LOS BANOS MEMORIAL HOSPITAL

SEVIER VALLEY MEDICAL CENTER

LINCOLN COUNTY MEDICAL CENTERBAYLOR REGIONAL MEDICAL CENTER AT PLANO

PARK CITY MEDICAL CENTER

HILLCREST BAPTIST MEDICAL CENTER

Lowest Rates

ALTA BATES SUMMIT MEDICAL CENTER

ALTA VIEW HOSPITAL

AMERICAN FORK HOSPITAL

BAYLOR ALL SAINTS MEDICAL CENTER AT FW

BAYLOR HEART AND VASCULAR HOSPITAL

BAYLOR MEDICAL CENTER AT CARROLLTON

BAYLOR MEDICAL CENTER AT GARLAND

BAYLOR MEDICAL CENTER AT IRVING

BAYLOR MEDICAL CENTER AT WAXAHACHIE

BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE

High Performing Hospital Highlight… Most Improvement

Inpatient Falls with InjuryMost Improvement

SUTTER LAKESIDE HOSPITAL

SUTTER COAST HOSPITAL

DELTA COMMUNITY MEDICAL CENTER

LINCOLN COUNTY MEDICAL CENTER

PROVIDENCE PORTLAND MEDICAL CENTER

PROVIDENCE NEWBERG MEDICAL CENTER

UPPER CONNECTICUT VALLEY HOSPITAL

CASSIA REGIONAL MEDICAL CENTERBAYLOR REGIONAL MEDICAL CENTER AT PLANO

PARK CITY MEDICAL CENTER

Lowest Rates

ALTA BATES SUMMIT MEDICAL CENTER

ALTA VIEW HOSPITAL

AMERICAN FORK HOSPITAL

BAYLOR ALL SAINTS MEDICAL CENTER AT FW

BAYLOR HEART AND VASCULAR HOSPITAL

BAYLOR MEDICAL CENTER AT CARROLLTON

BAYLOR MEDICAL CENTER AT GARLAND

BAYLOR MEDICAL CENTER AT IRVING

BAYLOR MEDICAL CENTER AT WAXAHACHIE

BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE

Just One Thing MatrixRecommendations

Getting Started Working Harder Ahead of the Curve

Implement standard Assessment tools, protocols and prevention strategies

(high level of evidence)

Appoint “leads” to drive improvement & identify or champion teams that includes unit level nursing, quality, patient safety, physical therapy and pharmacy services. (high level of evidence)

Implement decision algorithms and/or computerized decision support in the electronic medical record to target interventions based on patient specific risk factors

• Set Organizational priority

• Identify Risks and Gaps

• Develop Monitoring Systems

• Designate Champions

• Integrated Nurse Charting and Care Plans

• Repeat Cycles of ‘Plan-Do-study-Act’

Getting Started and Keeping it going!

Fall Event #1Case 1: 9:13:48 AM• Pt noted during rounding sleeping soundly @ 0200, was not woken up. Pt found on

floor by CNA @ 0240. • Pt reports going to the bathroom on her own, took herself off the CPM, SCD, and

went to the bathroom without a walker, stated "I really needed to go to the bathroom, that's why I didn't call," fell backwards and hit her head on the side of the counter. Pt alert and orient before and after fall.

• Pt noted previously using the call light for help, and agreed at the beginning of the shift to call when help is needed, but decided to be noncompliant this time. VS done. No abnormality.

Post fall: • Only noted injury is hematoma to left forehead. Dr. MJ notified, no new orders

given except to monitor patient during the night. Pt re-educated about fall risks, bed alarm activated, sign on door, and monitored frequently. Post fall: Pt re-educated about fall risks, bed alarm activated, sign on door, and monitored frequently.

Fall Event #2Case 2: 12:43:55PM • Aide was sitting at desk documenting end of shift vital signs when patient's

bed alarm went off. Aide stood up look through the doorway and saw patient on knees next to the side of the bed. Bed alarm and side rails were in place at the time of the fall. When asked patient reported he wanted to roll onto his side. Lift was used to return patient to the bed, vital signs obtained RN notified, RN assessed patient, palpated joints. Patient reports pain on palpation of patella and anterior aspect of knees and shins bilaterally.

Post Fall: • MD notified, Family Notified. Could have possibly been prevented if patient

had a sitter in the room. Nursing and CNA staff had repeatedly reinforced to Patient, the hospital safety protocols for ambulation and transfer require staff assistance.

Fall Event #3

Case 3:• You have identified 10 patients on your unit with a high risk for

falls, what intervention do you implement?

• Based on your experience, which interventions are the most effective?

• How would you document the assessment and intervention(s) for

the patient in your EHR?

• What type(s) of performance feedback would be available at the unit level?

Fall Event #4• You are a nurse manager on a 40 bed MedSurg unit with a hospital

mandate to reduce falls with limited resources.

• Issue: Identify patients at risk for falls.

• How would you identify the patients? How would you stratify the individual patient’s risk? Who would screen the patient? What key factors contributed to the decision?

• How would you document the assessment and intervention(s) for the patient in your EHR?

• What type(s) of performance feedback would be available at the unit level?

Fall Event 5

• Budget cuts have forced reduction in the number of patient care techs (PCT) and nursing staff. What tactics would you use to minimize fall risk?

• How would you maintain what you have implemented?

Fall Prevention Best Practice

• Use our HEN bundle to assess practice?

• Or use the Veterans Integrated Service Network 8 (VISN 8) Road Map?

• http://www.mnhospitals.org/Portals/0/Documents/ptsafety/falls/falls-prevention-roadmap.pdf

2014 plans for improvement

• Reach out to low performers to provide assistance.• Held regional workshop in Plano Texas• Shared case studies

• Collect and share best practices across network hospitals • Review/revise 2013 proposed prevention bundle • Conduct participant practice survey

• Next webinar plans? • Questions• Issues• barriers